Essentials of Orthopedics for Physiotherapists John Ebnezar, Rakesh John
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1
General Principles of Physiotherapy Treatment
  • General Principles of Physiotherapy
  • Role of Physical Agents in Physiotherapy
  • Massage
  • Hydrotherapy
  • Suspension
  • Therapeutic Exercises
  • Ambulation After a Lower Limb Fracture
  • Wheelchairs
2

General Principles of Physiotherapy1

Orthopedics has come a long way since the days of Nicolas Andry—a French physician, who is credited for coining the term, orthopedics from two words, ortho = straight and pedics = child in 1741.
What was a primitive branch then restricted to correcting deformities in children, has developed into a full-fledged specialty with diverse scope ranging from simple treatment, as done by traditional bonesetters to highly advanced joint, spine and hand surgeries.
The development of orthopedics as a specialty was pedestrian till 18th century. The discovery of anesthesia and aseptic surgical techniques opened up new avenues of treatment like open reduction, debridement, etc. The discovery of X-rays by Roentgen and the introduction of the usage of plaster of Paris by Albert Mathysen in 1852 revolutionized the diagnosis and management of orthopedic disorders. Thus, orthopedics started breaking through the deadlocks of a crude branch to that of a science.
But what really set the ball rolling was the sudden surge of orthopedic cases firstly by the two World Wars and of late by the road traffic accidents, which is on the rise, both in the developed and developing countries.
Polytrauma, multiple fractures, high-velocity injuries, severely exposed the limitations of the conventional treatment in orthopedics, as the fracture patterns were bizarre and complicated. Thus newer modalities of treatment such as improved methods of internal fixation, the Association of Osteosynthesis (AO) systems, the interlocking nail system, Ilizarov method, etc. were introduced into orthopedic management. Suddenly orthopedics was being considered a highly specialized branch with vast scope.
Needless to say many pioneers both at the international and national level have contributed enormously for the development of this branch to the present what is today. We salute them for their contribution. A fitting tribute to them is to carry on the good work done by them and to raise the level of this branch to such dizzy heights so that the sufferings of mankind due to orthopedic disorders are mitigated.
But orthopedic treatment does not end at merely fixing the fracture efficiently. The preinjury functional status of the individual has to be restored back and further complications or recurrence of the problem has to be prevented. This is where the specialty of physiotherapy steps into bridge the gap in treatment. In fact orthopedics and physiotherapy are two faces of the same coin. A good orthopedic surgeon is one who has a good physiotherapist within himself while a good physiotherapist is one who was a sound knowledge of orthopedics. While the orthopedician fixes the fracture, a physiotherapist rehabilitates the patient back to normal or as near normal as possible. Similarly in chronic orthopedic disorders merely managing the patient conservatively or surgically is not sufficient. Here also rehabilitation of the patient is extremely important and the role of the physiotherapist is sometimes more important than that of the therapist.
Thus, a perfect blending of the art of orthopedics and physiotherapy is what is required to put the patient back to the preinjury status. While the role of an orthopedician begins after the fracture or after the disease strikes. The role of a physiotherapist does not start after the fracture is fixed or after the disease is healed, but starts from day 1 of the onset of disease or fracture. Apart from the therapeutic role, physiotherapy has a restorative role in restoring the lost function but also has preventive role in preventing the recurrence of the problem. Here physiotherapy plays a very important role in the rehabilitation of a patient suffering from fractures or any other orthopedic-related disorders.
Thus, orthopedic physiotherapy is an important branch of medicine, which has come to occupy the center stage of the treatment of orthopedic-related disorders, which is some he has to assist the orthopedic surgeon in treating a patient while in others he has to play a leading role.
Thus like never before, a physiotherapist needs to have a comprehensive knowledge of orthopedics to treat these 4patients better. He has to begin by making a proper diagnosis of the orthopedic problem before he embarks on treating them with the vast armamentarium of physiotherapy treatment modalities available at his disposal.
 
DIAGNOSIS IN ORTHOPEDICS (APPROACH TO A PATIENT WITH ORTHOPEDIC DISORDERS)
As in other branches of medicine, the diagnosis of orthopedic disorders revolves around the following fundamentals (Fig. 1.1 and Box 1.1).
So we will try to discuss in brief the three steps of diagnosis in orthopedics.
 
At the End of History
History is ‘His- Story’, as told by the patient. History taking is an art. Caution has to be exercised in the story ‘told’ and the story ‘untold.’ Everything told should be taken with a pinch of salt lest the examiner is misled.
 
Certain Points of Importance in the History
Age: Certain diseases have predilection for certain age groups (Table 1.1), e.g. Perthes disease and acute osteomyelitis are common in children. Avascular necrosis and degenerative disorders are common in the elderly. Some diseases may be seen in all the age groups, e.g. tuberculosis of bone and joints.
Sex: Congenital dislocation of hip (CDH) is common in females. Congenital talipes equinovarus (CTEV) is more common in males.
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Fig. 1.1: Fundamentals of diagnosing orthopedic disorders
TABLE 1.1   Age versus orthopedic disease
Age
Diseases
< 1 year
Congenital dislocation of hip and cerebral palsy
1–2 year
Nutritional rickets
Poliomyelitis
Nutritional rickets
Poliomyelitis
Ewing's tumor
5–10 year
Tuberculosis of hip
Perthes’ disease
15–20 year
Slipped capital epiphysis
< 15 year
Osteomyelitis
10–20 year
Bone malignancies
30–40 year
Rheumatoid arthritis
> 40 year
Degenerative disorders
Protruded intervertebral disk (PIVD)
Multiple myeloma, etc.
Onset: It may sudden or gradual.
Trauma: It could be a predisposing factor or the causative factor and it is usually due to road traffic accident (RTA), fall, assault, etc. (Fig. 1.2 and Box 1.2).
Fever: It may be high as in acute osteomyelitis or low grade as in tuberculosis.
Pain: This could be continuous or intermittent, low or high grade. One should be on guard about the radiating pains as these often mislead the examiner (Table 1.2).5
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Fig. 1.2: Road traffic accidents (RTA) are a common cause of bone and joint injuries
TABLE 1.2   About radiating pains (Fig. 1.3)
Region
Radiation sites
Cervical spine
Shoulder, arm, forearm and fingertips
Upper limbs
  • Shoulder
  • Elbow
  • Arm and elbow
  • Forearm
Thoracic spine
Girdle pains
Lumbar spine
Groin, buttocks, posterior thigh, legs and foot
Hip
Knee
Any constitutional problems such as weight loss, anorexia, etc. if present are a pointer towards neoplasm, tuberculosis, etc.
Seasonal variation: If present it is suggestive of rheumatoid disorders. Apart from these points, relevant past history, socioeconomic status and personal history should be taken into account. An attempt should be now made to place the problem into one of the following categories at the end of history taking (Table 1.3).
Is the problem congenital?
If so, it will be present since birth or seen within few years from birth. A strong family history is elicited able.
Is it developmental?
Here the disease gets manifested during the process of development.
Is it an infective disorder?
History of fever, chills, rigors, sweating, etc. are present.
Is it inflammatory disorder?
Seasonal variation, remissions and exacerbation, multiple joint involvement, etc. are present.
Is it a metabolic disorder?
Nutrition, socioeconomic status, generalized skeletal disorder, etc. assume importance in this group.
TABLE 1.3   Diagnostic facts
Facts
Types
Present since birth
Congenital
During the development process
Developmental process
History of fever, chills, rigors
Infective
Nutrition, socioeconomic status
Metabolic
Other evidences of hormonal imbalance
Endocranial
Seasonal variation, multiple joint Involvement, etc.
Inflammatory
History of road traffic accident (RTA), fall, assault
Traumatic
Features of either benign or malignant
Neoplastic
Advancing age, etc.
Degenerative
If no obvious complaints
Idiopathic
Is it an endocranial disorder?
Look for other evidences of hormonal imbalance, e.g. hypothyroidism → cretinism, hypopituitarism → dwarf, etc.
Is it traumatic?
History of fall, road traffic accident (RTA), assault etc. is elicited.
Is it degenerative?
Advancing age, slow progress is the hallmark.
Is it neoplastic?
Look for the features of either benign or malignant bone tumors. If it cannot be categorized into any of the above, then it could be idiopathic. Having made a tentative diagnosis at the end of history, next important step is resorted to.
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Fig. 1.3: Radiating pain at the upper limbs, chest and lower limbs
6
 
EXAMINATION
A good systematic clinical examination will help to clinch the diagnosis with certainty. No sophisticated technology can replace the value of a good clinical examination. A good clinician will make the diagnosis clinically and will make use of the investigation armamentarium judiciously. A clinician should command the investigation and not vice versa. Examination of the locomotor system involves four steps.
 
Step I
 
Examination of Gait
An examination of the gait is extremely important as it gives vital clues regarding the diagnosis.
 
Definition
It is a term used to describe the style of walking. This is dependent not only on normal muscles and joints but also upon an intact central nervous system (CNS), peripheral nervous system and normal labyrinthine function (for details refer Chapter 50 ‘Human Gait’).
 
Step II
 
General Physical Examination
A good general physical examination (GPE) from head to toe gives vital clues in the diagnosis of most of the orthopedic disorders, particularly generalized disorders of the skeleton, for example:
  • Metabolic disorders, e.g. rickets, etc.
  • Developmental disorders, e.g. osteogenesis imperfecta, etc.
 
Step III
 
Clinical Examination
The following are the usual presenting symptoms in a patient with orthopedic disorders.
Pain: This is the first and the most common complaint. It is a highly subjective complaint and can be classified as mild, moderate or severe. The must-ask questions regarding the pain are how did it start? Is it related to trauma? Site of pain? Does it radiate? What are the aggravating and relieving factors? Does it interfere with sleep? etc.
Swelling: It may precede or follow pain. Relevant questions to be asked are—site of the swelling, painful or painless, is it rapidly growing (e.g. malignancy) or slow growing (benign growth), is it associated with fever, chills, etc. (e.g. infective origin), single or multiple (e.g. neurofibromas, etc.).
Deformity: Sudden onset of deformity is usually seen in fresh fractures and dislocations. Long-standing deformities are usually seen in old fractures and other non-traumatic disorders such as congenital, developmental, and metabolic conditions. Patient may complain of cosmetic and functional impairment due to the deformity.
Limitations of joint movements: In the initial stages, it may be due to muscle spasm and in the later stages it may be due to intra-articular adhesions [e.g. tuberculosis (TB), septic arthritis, rheumatoid arthritis, etc.)] or extra-articular contractures (such as postburn contractures, Volkmann's ischemic contracture, etc.).
Limp: This could be painful (e.g. arthritis of hip, trauma, etc.) or painless (e.g. CDH, coxa vara, etc.). Patient may complain of difficulty or alteration in various day to day activities like walking, squatting, running, working, etc.
Limb weakness: This may be due to disuse atrophy, motor problems such as polio, motor nerve disease, etc. muscle problems such as muscular dystrophies, etc. or due to peripheral or diabetic neuropathies.
 
Signs
General: Look for the signs of anemia, fever, weight loss, etc.
Local: Deformity may be due to an abnormality of bone or joint. If a joint is out of its anatomical position, a deformity is said to exist. And in case of bone, deviation from its normal anatomy is deformity. In cases of old fractures and dislocations, the deformity may be fixed.
Temperature: This is always compared with the normal side. Check with dorsum of the hand as this is the most sensitive part.
Tenderness (Fig. 1.4): This is elicited by examining from the normal to the affected area and is graded I to IV (see p. 30).
Swelling: The following things are noted in the examination of a swelling:
  1. Decide the anatomical plane. The plane of the swelling could be either bone (swelling decreases in size when muscle is put into contraction) or could be in the muscle (swelling slightly decreases in size and gets fixed on muscle contraction) or could be between the muscle and the skin (no change in the size at the swelling when muscle is put into contraction).
  2. Describe the shape as globular, oval or round, etc.
  3. Grade the consistency.
  4. Decide whether it is congenital, neoplastic, etc. (refer Table 1.3).7
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    Fig. 1.4: Method of eliciting joint line
  5. Look for slipping sign, sign of emptying, indentation sign and expansile impulse.
 
Movements of Joint
Active movement: Patient himself moves the joint in one direction and later in the other. The extent of active movement is noted. Both the joints should be tested.
Passive movement of the joint is tested by the examiner without causing pain. The extent of passive movement is noted.
 
Measurements
Accurate limb length measurements give vital clues regarding the diagnosis. Measurement should be taken for two purposes.
 
To know the limb length
For this measurement is taken between two fixed bony points and is always compared with the normal.
 
Upper limbs
  • Arm length: From the angle of acromion to the lateral epicondyle of humerus (Fig. 1.5)
  • Forearm length: From the lateral epicondyle of humerus to the radial styloid process.
 
Lower limbs (Fig. 1.6)
  • Thigh length: From anterior superior iliac spine to the medial knee joint line
  • Leg length: From the medial knee joint line to the medial malleolus
  • Entire lower limb length: It is measured from the anterior- superior iliac spine to the medial malleolus below.
 
To know the girth of the limb
To detect wasting of muscles, the circumference of the limb is measured at fixed points on both sides, e.g. 18 cm above joint line in the thigh (Fig. 1.7).
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Fig. 1.5: Method of upper arm length measurement
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Fig. 1.6: Method of measuring lower limb girth and checking the movement
8
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Fig. 1.7: Method of measuring the length of lower limb
 
Irregular thickening of bone and persistent discharging sinus (Fig. 1.8)
If this is present along with scars fixed to bone, it indicates osteomyelitis.
Peripheral, vascular and nervous system examination should be done next. This is discussed in appropriate sections.
 
Step IV
 
Investigations
These help to confirm the diagnosis and in some cases help to make the diagnosis (e.g. crack fracture, etc. can be diagnosed only by X-ray). One has to choose carefully from the following vast armamentarium,
 
Routine laboratory investigation
Routine laboratory investigation consists of blood investigations such as routine hemogram, urine examination, electrocardiogram (ECG), chest X-ray, etc.
 
Special investigations
Radiography: At least two views of the affected part should be taken, oblique views and some special views are required in some cases.
Computed tomography (CT) scan: To study the cross-section of the limb anatomy and bones.
Magnetic resonance imaging (MRI): This is the recent gold standard in the investigative armamentarium of bone disorders. It helps to study the bone, soft tissues, medullary spread, etc. with greater accuracy. The only problem is its prohibitive cost.
Angiography and biopsy in tumor diagnosis. Thus, a reasonably accurate diagnosis can be made by following the guidelines discussed above.
 
Treatment Methods
After having made a diagnosis, the orthopedic surgeon proceeds to treat the condition. The conventional treatment methods in orthopedics are conservative management, surgical management and physiotherapy. Treatment of fractures, their complications and other orthopedic disorders are discussed in relevant sections. Emphasis in this chapter is the role played by the physiotherapist and the various treatment modalities at his command.
 
Role of a Physiotherapist
In treating fractures and other orthopedic related disorders, a physiotherapist is required to play the following roles:
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Figs 1.8A and B: Irregular thickening of bone and discharging sinus due to chronic osteomyelitis. A. Schematic diagram; B. Clinical photograph
  • Rehabilitation is a team effort and he/she is part of a team
  • He/she has to make a subjective and objective assessment of patient's condition and needs
  • To decide on the form of treatment and explain it to the patient
  • 9To do cardiopulmonary conditioning before subjecting the patient to the rigors of physiotherapy
  • To restore the lost functions.
 
Assessment
By careful clinical examination mentioned above he makes an assessment of the problems of the patient and how he/she should go about to rehabilitate him back to normal. His/Her plan of treatment should aim to fulfill the following short- and long-term goals.
 
Short-term goals
These include:
  • Limit the bleeding if any
  • Further damage should be prevented at all cost
  • Pain and swelling should be reduced
  • Prevent joint stiffness and contractures
  • Preserve the muscle power.
 
Long-term goals
These include:
  • Kinesthetic and proprioceptive mechanism to be restored back to normal
  • Mobility of joint and soft tissue to be increased
  • Muscle power to be increased
  • Movement re-education
  • Daily functional activities to be restored back
  • Prevention of swelling and recurrence of the injury
  • Restoring back the postconfidence to the affected limb and person.
Note: There are two categories of patients who need long-term physiotherapy:
  1. Prolonged physiotherapy for a short time: For example, after hip/knee surgeries, etc. Here prognosis is good and patient may resume full or near normal function.
  2. Prolonged physiotherapy almost permanent: For example, patients with hemiplegia, paraplegia, etc. where the chances of recovery are extremely bleak.
After having made a thorough assessment of the problem and having determined the short- or long-term goals, the therapist plans the rehabilitation program such as exercises, physical agents, massage, etc. But before subjecting the patient to the rigors of prolonged or vigorous physiotherapy, he/she has to determine whether the heart, lung and general condition of the patient is fit enough to with start the stress. If not, he/she has to make the cardiac and the lungs fit through sustained efforts as follows.
 
CARDIOPULMONARY CONDITIONING
Cardiopulmonary conditioning is defined as an exercise program aimed to improve the cardiac and pulmonary efficiency of the patient.
 
Benefits of CPC
  • It improves the functions of the heart and lungs
  • It improves metabolism, glucose tolerance, hormone production, hemodynamics, etc.
  • It improves muscular strength, endurance, joint and muscle flexibility, neuromuscular skeletal system, coordination, exercise tolerance, etc.
Due to the various benefits of CPC, they are widely recommended before resorting to the routine orthopedic physiotherapy measures. A candidate for CPC is chosen after preliminary screening of risk factors for heart diseases, clinical examination and evaluation for assessing the existing heart conditions, exercise tolerance, etc. and then finally formulating the exercise program for the patient.
The exercises chosen are isotonic, isokinetic and isometric ones. The intensity, duration and frequency of exercises chosen are individualized depending on the patient's condition. The conditioning exercises chosen are done in three phases namely the warm-up phase, conditioning phase and cool-down phase.
After a thorough CPC, orthopedic physiotherapy can now be instituted by the therapist. Orthopedic physiotherapy consists of therapeutic exercises, physical agents, massage, traction, manipulation, assistive devices, ergonomics, ambulation, etc. Each of the above methods will be described in detail in relevant sections.